Abstract

Aim: This paper presents four key elements for developing infrastructure to address health disparities
which are social justice, social determinants of health, interprofessional practice, and community
engagement.
Method: These elements are then illustrated within a nurse-led interprofessional practice exemplar.
Conclusion: Using these key elements, there is great potential for developing and carrying out a
community-based participatory research agenda to address health inequity within a nurse-led
interprofessional practice setting.

1. Summary Statement

What is already known about this topic: Health is a complex
interaction of social, economic and contextual conditions that have
a cumulative effect over the life course. Nursing has identified an
imperative to address social injustice with an understanding of its
relationship to health disparities.

What this paper adds: This paper discusses social injustice,
interprofessional practice and development of community partnership
as it relates to the development of a sustainable health disparities
research agenda and it application in a nurse-led health care center.

Implications of this paper: This paper provides both theoretical
underpinning and a real world exemplar of a strategy to develop a
community based participatory research agenda to address health
inequity within a designated community.

Nursing as a profession has consistently focused on the mental and
physical well-being of others – individuals, families, communities and
populations. As nurses strive to support this wellbeing, they must
be knowledgeable of those complex factors that affect an individual’s
ability to experience optimal health. Globally, nursing literature
has broadened to increasingly focus on social and environmental
factors on health and assist nurses to enhance how we view, and
practice, nursing to address health disparities among underserved
populations. Within the last 10 years, the health disparities literature
has consistently identified key elements which can support knowledge
development and change in nursing practice. These key elements are
social justice, social determinants of health, interprofessional practice
and community engagement.

Elements for Developing Infrastructure to Address Health
Disparities

1.1 Social Justice and Nursing

Social justice as a construct has been explored by a vast array of
professions. The concept has been found in the literature as far back
as the writings of Plato. Theologians Thomas Aquinas (1225-1274)
and John Locke (1632-1704) as well philosopher Immanuel Kant
(1724-1804) are widely seen as key contributors to the early
underpinnings of current social justice ideals. The contemporary
concept of social justice is generally associated with the work of John
Rawls (1921-2002). In Rawls’ A Theory of Justice [1] he proposes,
“Each person possesses an inviolability founded on justice that even
the welfare of society as a whole cannot override. For this reason,
justice denies that the loss of freedom for some is made right by a
greater good shared by others”(p3-4). Rawls [2] states “justice is the
first virtue of social institutions” (p 113). This philosophy is based
on the two moral powers 1) a of sense of justice and 2) conception of
the good.

Social justice principles, whether implicit or explicit have been
incorporated into nursing practice since its inception. Many of
Florence Nightingale’s writings address the need to consider the
influence of social issues on health. In a synthesis of Nightingale’s
writings, Selanders and Crane [3] identified that Nightingale set forth
the premise that thework of nursing should not be limited by gender,
spiritual beliefs or values of those they serve. Lillian Wald, viewed as
the founder of modern public health nursing, established the Henry
Street Settlement House, in New York City in the late 1800’s where
the poor could receive medical care and access to social services.
Wald grounded her efforts “in the belief that the world was simply an
expanded version of a culturally diverse neighborhood” [4].

Overtime, nursing education has demonstrated the importance
of mandating the inclusion of social justice concepts at every level
of instruction and as part of the American Nurses Association Code
of Ethics. The American Association of Colleges of Nursing
(AACN) Essentials guidelines identify the need to address social
justice concepts in bachelor’s programs [5], master’s education [6],
and in doctoral preparation for advanced practice [7]. The AACN
mandate for this content validates nursing’s commitment to assisting
our students in preparing to meet the challenge of addressing social
justice issues and recognizing their relationship to health.

The American Nurses Association [ANA] Code of Ethics with
Interpretative Statements [8] addresses the role of the nurse as part
of collaborative practice and collaborative research. In addition, it
included specific language focused on the responsibility of the nurse
to address social injustice with an understanding if its relationship
to health disparities. Provisions 7-9 of the Code provides support
for nurses in the development and leadership of interprofessional
practice, to hold a greater understanding and application of the
social determinants of health model, and the expectation for nursing
research and scholarship that best addresses the complex needs of
populations especially those that are underserved and experiences
health disparities due to social and economic disadvantage.

1.2 Social Determinants of Health and Health Inequity

The World Health Organization [9] defines Social Determinants
of Health (SDH) as “the conditions in which people are born, grow,
work, live, and age, and the wider set of forces and systems shaping the
conditions of daily life. These forces and systems include economic
policies and systems, development agendas, social norms, social
policies and political systems” [9]. These contextual factors affect
people’s exposure to environmental risks, vulnerability to illness,
access to care, and ability to undertake healthy behaviors or manage
health conditions within their home settings. Social determinants are
often the foundation of poor health and are critical to understanding
health disparities.

The complex interaction of social and economic conditions that
affect health include education, income, employment, neighborhood
characteristics, and social conditions and contexts as well as culture
and beliefs about health. Individuals with low education and income
are more likely than better-educated, higher-income individuals to
lack a stable job, safe housing, food security and adequate income to
meet health needs. Inequity in resources result in increased morbidity
and mortality and these interactions have a cumulative effect over the
life course for individuals, families and communities [10-16].

1.3 Interprofessional Education, Practice and Research

The ability to address health needs with a social justice perspective
cannot be accomplished by nursing or other disciplines in silos.
Therefore, addressing the social justice imperative necessitates
collaborative, interprofessional practice, education and research.
Interprofessional education (IPE) is becoming an essential element
in the preparation of healthcare professionals for interprofessional
collaborative practice(IPP) and research. IPE has been shown to
improve healthcare delivery and health outcomes with the Institute
of Medicine [17] urging interprofessional collaboration in healthcare
to improve the quality of care. Socialization into health professions
roles involves mutual learning through interactions with professionals
from other disciplines to understand their roles, values, attitudes,
skills, behaviors, and norms [18]. Although the IPE and collaborative
practice movement began about 40 years ago, high quality evaluation
research remains critical to show their effectiveness [19].

Healthy People 2020 [20] recognized the importance of
interprofessional education and practice in meeting community
health needs, specifically stating in Educational and Communitybased
Program Objective 19 (Office of Disease Prevention &
Health Promotion [ODPHP], n.d.) that the goal is to, “Increase the
proportion of academic institutions with health professions education
programs whose prevention curricula include interprofessional
educational experiences” [21]. Deutschlander et al. [22], in their
systematic review of the literature, concluded that “offering these types
of IPE experiences has also shown to influence student’s first place of
employment at graduation, especially in rural and urban primary care
specialties involving underserved populations” (p.1). Settings such as
these experience significant health disparities, and inequity in health
care access and service availability. Increasing providers committed
to underserved populations directly impacts inequities in access and
service availability.

The importance of a clear research agenda surrounding IPE and IPP
cannot be overstated. However, there is considerable discussion on the
manner in which this can be done(i.e. what actually can be measured
and what is the most appropriate methodology). The work of Brandt
et al. [19] and Goldman et al. [23] identify that previous research has
focused on three types of impact (of IPE/IPP). These are short-term
changes on the learner; practice-based processes and organizational
level policy change. The Institute of Medicine published Measuring the
Impact of Interprofessional Education (IPE) on Collaborative Practice
on Patient Outcomes[24] to aid in clarifying how IPE/IPP might
be studied. The report offers extensive guidance related to study
design and identifying types of outcomes that could realistically be
measured. In addition, the report discusses a key element that had
not been fully explored previously which was the recommendation
for inclusion of patient, family and caregiver experiences with the
goal of improved alignment between education and practice as well as
improved person-centered and community-centered outcomes. The
report states that,

“Addressing these gaps will entail giving IPE (and IPP) greater priority
by forming partnerships among the education, practice, and research
communities to design studies that are relevant to patient, population,
and health system outcomes. Engaging accreditors, policy makers,
and funders in the process could provide additional resources for
establishing more robust partnerships. Only by bringing all these
constituencies together will a series of well-designed studies emerge.”
(Institute of Medicine [24])

This document supports engagement of patient and community as
important partners in this area of research as providers strive to be
better equipped and thereby improve health outcomes and address
health disparities.

1.4 Community Engagement, Partnership and Health Equity

Health practitioners and researchers have increasingly used
community engagement in the context of health promotion and
disease prevention. The Centers for Disease Control and Prevention
(CDC, 1997) has defined community engagement as “the process of
working collaboratively with, and through, groups of people affiliated
by geographic proximity, special interest, or similar situations to
address issues affecting the well-being of those people”(p 9). The
Principles of Community Engagement[25] document identifies that
“community engagement is grounded in the principles of community
organization: fairness, justice, empowerment, participation, and self
determination” (p 4). A growing body of research has clearly identified
that ecological factors support health or influence the development of
disease. Because health is socially determined to a great extent, then
health issues are best addressed by engaging community partners
who bring their own understanding, concerns, values and priorities.
Through this approach, trust is built, coalitions are formed and
innovative solutions are identified which are culturally and socially
congruent. These solutions are more sustainable because community
partners are invested in those solutions and they are tailored to the
needs of those being served. Also of importance in community
engagement is the focus on the underlying principles of equity and
justice which is enacted through the bidirectional partnership between
practitioners and/or researchers and the identified communities.

Key characteristics of community engagement are the critical
nature of building trust, supporting empowerment, role definition
and collaborative decision-making among partners. Even as this
process is occurring, interprofessional team building is also occurring.
Both require time, resource development (human and financial)
and relationship cultivation as essential infrastructure that supports
innovation, improved outcomes, outcome measurement and the
development of a community based participatory research agenda in
collaboration with community stakeholders.

The Principles of Community Engagement [24] identify that
the community based participatory research model includes
clear delineation of 1) contexts, 2) group dynamics and equitable
partnerships, 3) collaboratively developed intervention strategies and
4) outcomes that are focused on system change to address inequality
in health and health care.

2. Methods

The following is an exemplar of a unique clinical setting that
has systematically applied the elements of social justice, social
determinants of health, interprofessional practice, and community
engagement to build an infrastructure that is well suited to address
health disparities, develop educational approaches and CBPR
research.

2.1 Kentucky Racing Health Services Center

Established in 2007 as a nurse practitioner managed health center,
the Kentucky Racing Health Services Center (KRHSC) provides a full
range of health care services to the un- and under-insured workers
in the Kentucky thoroughbred horse racing industry. The KRHSC
is located at the Churchill Downs racetrack which is a horse racing
setting in Louisville Kentucky, USA and the home of the worldrenown,
annual Kentucky Derby. The KRHSC is a collaborative
program between the Kentucky Racing Health and Welfare Fund,
Churchill Downs and the University of Louisville School of Nursing.

The Kentucky Racing Health and Welfare Fund consists of
money allocated by the Commonwealth of Kentucky which comes
from unclaimed winnings generated from bets placed at Churchill
Downs during the racing season. If winning, horse racing tickets are
not cashed by their owners, a portion of that money goes into the
Kentucky Racing Health and Welfare Fund as determined by the state.
The University of Louisville School of Nursing identified the unmet
health care need of the racetrack workers as a result of their clinical
experience, the School of Nursing developed a service proposal and a
collaboration was formed with Churchill Downs using Racing Health
and Welfare Funds to provide the needed care.

The KRHSC serves a primarily Spanish-speaking population with
scheduled office visits and same day visits, and there is no charge for
the provided services. The individuals that are served migrate across
the United States as part of their work in the horse racing industry.
Horse racing tracks have meets or sessions at different times of the
year and workers follow this schedule. Following this schedule can
mean traveling thousands of miles several times per year to continue
their employment. Horse racing tracks in states such as New York,
Louisiana, Florida, Arkansas and others provide what health services
they can for workers, but care is fragmented and not always available.
The migratory nature of this work makes delivering quality, sustainable
health care challenging at best.

Along with physical health services, the program has recently
expanded to include mental health services based on the identified
needs of the population being served. There is an interprofessional
provider team including advanced practice and registered nurses,
physicians, dentists, and translation/culturally tailored services. Since
its inception, the KRHSC averages approximately 2,000 office visits
per year. Nurse practitioner faculty from the University of Louisville
School of Nursing see patients 2 ½ days per week and adjust the
schedule to meet the needs of this migratory population. KRHSC
services primarily occur May-December annually and most patients
leave the area January through April to work at racetracks in the
warmer climates.

Beyond the services provided to this diverse community, the
Center is an invaluable service learning clinical site for students
studying nursing (BSN, MSN and PhD), Latin American and Latino
Studies and for undergraduates interested in considering a career in
medicine. Undergraduate community nursing students routinely
provide educational offerings at the clinic that have a prevention
focus. The Center has provided the opportunity for several students
to complete pilot studies as a foundation for their master’s thesis
and doctoral dissertations. Outcomes from the service learning
programs and student projects are measured through identified
student learning outcomes and educational research. Clinical research
is also undertaken. Currently, research data is being collected to
examine Latino women’s perceptions regarding access to the KRHSC
health care services to better meet cultural and social needs of this
population.

Because of the migratory nature of the patient population, health
care follow up is challenging with many patients ceasing to take their
medication when they are away from the Center. As part of KRHSC
outcome improvement efforts, factors associated with medication
nonadherence are under investigation to address barriers to self-care
behaviors using the contextual knowledge about this population.
Efforts to better understand center patients and the community’s
needs necessitate creative research strategies that require a true
partnership between the KRHSC, the university and the horseracing
community that experience disparity in health.Table 1 identifies the
four key elements and how they were enacted within the KRHSC
setting (Table 1).

3. Conclusion

This exemplar provides a picture of the focus on social justice,
building community infrastructure for clinical services, professional
education and research in partnership with community funders, health
and non-health care professionals and the underserved population
themselves. A CBPR research agenda is underway resulting in an
evolving understanding of factors that impact this underserved
community. The goal for this center continues to be improved
health outcomes with resulting increased health equity. Building
infrastructure for successful CBPR to address health disparities is
multifactorial and interactive. Sustainability of the CBPR agenda is an
evolving process that is essential to improve health outcomes and to
address health inequity.

Table 1:
Key Elements and Exemplar illustrations.

Competing Interests

The author declare that there is no competing interests regarding the publication of this article.

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